This information is intended as a general introduction to this topic. As each person is affected differently by balance and dizziness problems, speak with your health care professional for individual advice.
Most people will benefit from some type of exercise therapy for imbalance and dizziness. Vestibular rehabilitation will not, however, help those with spells of acute, active, recurrent, spontaneous vertigo (spinning sensation) – for example, acute vestibular migraine or early stages of Ménière’s disease – because the brain cannot adjust to the changing nature of these disorders.
What is vestibular rehabilitation therapy?
Vestibular rehabilitation will help strengthen the bond between the body, eyes, brain and inner ear for most patients. During vestibular rehabilitation your symptoms are intentionally provoked in a safe and controlled manner to work towards getting your brain used to what makes you uncomfortable. Its overall goal is to increase quality of life by adapting you to your disorder, decreasing your symptoms and improving your overall function. Research suggests that rehabilitation programs are most effective when they are customized. The type, frequency, and intensity of effective exercises varies from person to person.
What practitioners do vestibular rehabilitation therapy?
Vestibular therapy is not a regulated title in Canada and vestibular rehabilitation is typically a special interest area. Training differs widely between therapists, from weekend introductory courses to more intensive competency-based courses with examinations. You may want to ask if the therapist has experience with your type of vestibular disorder.
You do not need a referral to see a physiotherapist, occupational therapist, or audiologist in private practice in Canada. For many Canadians, health insurance providers cover all cost or a portion of the cost. Some extended health insurance plans may require a doctor’s referral to reimburse you for service. Contact your health insurance provider to confirm your level of coverage and whether or not you need a referral for reimbursement.
The first visit includes a full assessment that allows the therapist to set up a suitable rehabilitation program. More extensively trained vestibular therapists will use special goggles to do a more thorough assessment.
Search our Practioners List to find professional members of our Society with advanced training in vestibular rehabilitation.
Will vestibular rehabilitation therapy make me dizzy?
The exercises should cause a mild to moderate increase in dizziness for only a few seconds. This slight increase in symptoms in the short term is what helps the brain make permanent changes to decrease dizziness in the long term. Little by little, your brain will be given a chance to overcome the dizziness.
You must be careful not to overdo it. It is not helpful to push through your symptoms. Tell your therapist if you become nauseated or develop a headache during the exercises, or if your symptoms do not decrease to their earlier level within 15-20 minutes. Your therapist will change the exercises to be sure you can tolerate them better. If you do an exercise and you feel no increase in dizziness, the therapist might be able to make it a little harder or you may not need to do that exercise anymore.
How long do I need to continue with vestibular rehabilitation therapy?
Vestibular rehabilitation and balance retraining exercises do not usually need to be continued indefinitely. Patients are advised to set goals for their rehabilitation program with their vestibular therapist. Once these goals are achieved a maintenance plan can be put in place. This should include finding a level of physical activity that is suitable for you and continues to stimulate and challenge the vestibular system enough to maintain a healthy balance. Keep the exercises in mind, however, should the symptoms come back.
If you are not seeing improvement despite ongoing vestibular rehabilitation therapy and balance exercises, you may have reached some limitations in terms of function. Diagnostic testing can help work out if this is the case.
Examples of vestibular rehabilitation exercises
Vestibular rehabilitation is tailored to your particular disorder and symptoms. Some exercises are specific, such as reducing symptoms to specific movements or visual stimuli. Other exercises may be related to improving your participation in self-care, household responsibilities, leisure activities, sports, driving, or work.
A vestibular rehabilitation program may include:
- Adaptation exercises
Help coordinate the vestibular ocular reflex (VOR). A properly functioning VOR allows you to keep visual targets in focus even when your head is moving. There are several types of adaptation exercises.
- Gaze stabilization exercises
Involve moving your head while keeping your eyes focused on a target. For the exercises to work, you must move your head as quickly as you can while looking at the target. It is normal to get a little dizzy or miss the target every now and then.
- Target shooting exercises
Work on keeping your head still while moving the eyes, or vice versa.
- Habituation exercises
Designed to reset the sensitivity of the nervous system. They help your brain get used to and ignore movements or situations that make you feel dizzy. This is done through repeated, controlled exposure to signals such as complex patterns and busy environments. You may do exercises indoors and outdoors. You may go on short trips to places that trigger symptoms, such as grocery stores or shopping malls.
- Balance retraining exercises
Done by standing on different surfaces and with increasingly narrow bases of support. They are helpful for improving steadiness to perform activities of daily living as well as to lower the risk of falling.
- Balance exercises with eyes closed.
Help reduce dependence on your eyes for balance by encouraging use of the vestibular system.
- Strengthening exercises
Improve muscle support of your body.
- Gait training
For example treadmill training and relearning to walk over unstable surfaces.
- Range of motion exercises
Help if you have been limiting movement of your head of body to minimize dizziness.
- Learning and practicing strategies
These help deal with or prevent your symptoms.
- Breathing and relaxation exercises
Help regulate the autonomic nervous system (the part of the nervous system that regulates key involuntary functions).
- Walking and other aerobic activities.
I’m unable to access a therapist – what can I do at home?
Vestibular rehabilitation and balance retraining is most effective when you follow a set of exercises tailored by a therapist to your specific needs. Some vestibular therapists offer video appointments. If you are unable to access a therapist, however, there are a number of exercises that can be done at home:
- Cawthorne-Cooksey habituation exercises
A graduated set of exercises that help relax the neck and shoulder muscles, train the eyes to move independently of the head, practice good balance in everyday situations, practice the head movements that cause dizziness , improve general co-ordination, and encourage natural unprompted movement.
- Gaining Balance video
Follow the graduated vestibular rehabilitation exercises presented on Balance & Dizziness Canada’s 35-minute video.
- Balance Retraining
An internet-based intervention developed by the University of Southampton. The exercises are similar to Cawthorne-Cooksey.
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Click on Vestibular Rehabilitation to see FAQ.
In general, there is nothing in particular that links vestibular exercises to making the crystals dislodge from where they belong, and thereby causing BPPV. Vestibular therapists have people doing a lot of different activities – in general, these are exercises done in an upright position, whereas BPPV is typically brought on by laying the head back. Vestibular exercises done for vestibulo-ocular reflex (VOR) or for balance do not tend to provoke BPPV. If BPPV is going to happen, it is going to happen – there is really no rhyme nor reason why the crystals tend to slide into a semicircular canal. And if they do, it is fairly easy for a vestibular therapist to correct.
You might feel a bit off balance, dizzy and/or nauseous for a day or two after an Epley manoeuvre, but these symptoms should settle down over time. For the most part, people tolerate the Epley manoeuvre quite well. If the therapist does repeated Epley or other manoeuvres – one, after the other, after the other – and your situation does not improve, it may be that something other than BPPV is causing your dizziness. In that case, following up with your vestibular professional and getting reassessed may help narrow down the cause.
I have been diagnosed with BPPV. My community has no support group for dizziness. I don’t know where to turn. Can you give me a plan of action?
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It is also possible that the source of your problem is not in the inner ear, but higher up in your brain. If the sensors in your brain that interpret the information sent by the ear are not working properly, these manoeuvres will be of no use.
Page updated May, 2021.